Implementation of methodologies for improvements in longitudinal care management for high risk patients

Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:

• Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;
• Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or
• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.

Evidence of longitudinal, or relationship-based, care management of patients at high-risk for adverse health outcomes as defined by the eligible clinician. Include both of the following elements:

1) List of high-risk patients – Identification of patients at high-risk for adverse health outcome or harm; AND

2) Use of longitudinal care management – Documented use of longitudinal care management methods including at least one of the following: a) empaneled patient risk assignment and risk stratification into actionable risk cohorts; b) personalized care plans for patients at high risk for adverse health outcome or harm; or c) evidence of use of care managers to monitor and coordinate care for highest risk cohorts.